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As the world slowly sheds the weight of COVID-19, there is an opportunity for psychiatrists to pause and consider the role they are about to play in the coming months and years. Never before has the entire modern world been subjected to such collective feelings of fear, uncertainty, anxiety, and sorrow—and loneliness.

Individuals around the world did their part to slow the spread of 

 by staying home. Populations that were not used to being alone, like children and teenagers, were suddenly cut off from their social networks. Family members were often isolated from each other. Many individuals have died from COVID-19, often without family, with little comfort or human contact except hospital staff.

About 36% of Americans reported feeling “serious loneliness” in the wake of the pandemic, according to 

 Of these respondents, 61% were aged 18 to 25 years, and 43% reported increases in loneliness since the pandemic began.

The effects of pandemic-related isolation have been felt in every corner of society. It may take the form of exacerbated symptoms in some patients or freshly developing signs of mental illness in others. Medically, loneliness has been linked to 

 It is also linked to increased rates of depression, anxiety, substance abuse, domestic abuse, and suicide.

Psychiatry often relies on pharmaceuticals to treat mental illness; this 

 serves as a good reminder that the best cure for loneliness can be as simple as kindness and compassion.

More than any other species, humans are dependent on others for longer periods of time. In fact, the average individual spends about 80% of their waking hours in the company of others.

 is a state of mind that is characterized by feeling unwanted, empty, and cut off from other human beings.

 It is also described as a negative reaction to the discrepancy between the relationships we desire versus those we have.

Loneliness is not necessarily the result of being alone. One can easily feel lonely even when surrounded by others. Because loneliness is more often a perception, feelings of isolation can trigger hypervigilance, in which the world appears to be a threatening place.

 Individuals who are lonely tend to be more critical of themselves.

 When these negative expectations are confirmed by the behavior of others, this creates a 

 that is accompanied by feelings of hostility, stress, pessimism, anxiety, and low self-esteem.

Loneliness apparently loves company, with studies describing it as 

 It appears to spread through friends, rather than family members, and occurs in clusters, extending up to 3 degrees of separation.

 Loneliness can be addressed both as a group and individually. One way to prevent loneliness is to encourage social activity. Obviously, for some people it is very hard to be social; this is where emphasizing resiliency and perseverance is important. 

“In loneliness, the lonely one eats himself; in a crowd, the many eat him,” Friedrich Nietzsche once said.

 Culturally, loneliness can be seen as a sign of weakness or self-pity. For instance, 1965 study of rhesus monkeys Found that when a group of socially isolated monkeys were reintroduced to their colony, they were driven off or eliminated.

In 2018, the United Kingdom’s BBC Radio 4 released results from 

, the largest survey ever conducted on the subject.

 They study included more than 55,000 participants, aged 16 to 99 years, hailing from 237 countries, islands, and territories. It found that loneliness was higher in individualistic cultures such as the United States and Western Europe, which placed high value on self-reliance, loose social networks, and chosen relationships. In contrast, cultures with strong collectivist norms, including some Asian countries, are built on interdependence, tighter social networks, and stronger family connections. Some of these countries include Brazil, India, and the Philippines.

The study found young individuals experienced the most loneliness, with 40% of 16- to 24-year-olds feeling lonely often or very often, in comparison with 29% of individuals aged 65 to 75. Young men in particular were more susceptible to feelings of loneliness, and their loneliness was more intense and longer-lasting.

Most of the research on loneliness was conducted before COVID-19 sent us into lockdown, so it is too soon to consider the pandemic’s long-term effects. However, recent studies have tracked the impact of social distancing and quarantine, and they have left an intriguing bread-crumb trail of predictions.

When COVID-19 struck, many experts worried suicide rates would skyrocket.

 A 2020 report from the Centers for Disease Control and Prevention showed a 35% increase in suicide mortality in the US from 1999 to 2018, a trend most people expected to continue.

A March 2020 rapid review disseminated 24 studies

 in 10 countries that examined the psychological impact of quarantine.

 It included those affected by SARS, Ebola, H1N1 influenza, Middle East respiratory syndrome, and equine influenza. Common quarantine side effects included posttraumatic stress disorder (PTSD), confusion, and anger. Stressors included the extension of quarantines, fear of infection, frustration, boredom, inadequate supplies and information, financial loss, and stigma.

The review also found health care workers in particular suffered from the loneliness and isolation of quarantine. Theyendured increased severe symptoms of 

, felt stigmatized, and reported greater loss of income. Health care workers also reported feeling lonely, guilty, angry, helpless, isolated, nervous, and sad. Many linked their quarantine experience to alcohol abuse and dependency symptoms. They also engaged in avoidance behavior, often not showing up to work or avoiding direct interactions with patients.

Like every facet of society, health and mental health organizations have had to rethink how to serve their patients, especially when they could not be treated in person. Mental health care providers were encouraged to find alternate ways to deliver services, provide clear pathways for those considering suicide, and quickly offer bereavement services when needed. We can assess for loneliness by using the revised University of California, Los Angeles (UCLA) loneliness scale.

 One way to approach the conversation is to ask patients what they are doing during their free time and if they have any friends or family they spend time with. Since the COVID-19 pandemic, it is likely a lot more patients have indicated they are lonely.

 examined the relationship between 30,000 patients and their therapists.

 In a review of 295 independent studies published between 1978 and 2017, it found that positive clinical outcomes correlated with the strength of the therapeutic alliance between patients and their therapists. The better the relationship, the better the prognosis. The therapeutic alliance has become even more important due to the pandemic and quarantine. As psychiatrists, we must strengthen our relationship with patients so they trust us and improve. This is just as important and essential as medication management.

Individuals need quality information and strategies to cope with loneliness, in addition to help identifying and managing self-defeating thoughts. Comprehensive assessments like the revised UCLA Loneliness Scale and access to round-the-clock counseling networks could throw vital lifelines to patients suffering from loneliness.

In France, the VigilanS suicide prevention system was implemented before COVID-19 began. It rapidly adapted by following up with at-risk patients on the 10th day rather than the 20th. Early data regarding this intervention shows a sharp decrease in 

 by those involved, however this is an ongoing study and final results are not yet published.

 France’s art community also jumped to provide support. Cov’ Art is a public art movement designed to shore up resilience and provide messaging about suicide and interindividual violence. Some programs in the US include the National Alliance on Mental Illness, the National Suicide Prevention Lifeline, and the American Foundation for Suicide Prevention.

, smartphones, and videoconferencing have also played a huge role in maintaining connections. Prior to COVID-19, social media was seen as something that made many individuals feel lonely.

 During the pandemic, however, social media was one of the few safe ways to stay in contact with other people. In one study, it was noted that while adolescents indicated increased social media use during lockdown, it was not associated with increased happiness. It even showed a negative correlation between using social media and happiness. It also noted that using social media as a substitute for physical social relations makes adolescents feel less happy.

More than anything, individuals need to be comforted that they are not alone and shown a way to overcome their loneliness. Often, the solution is to address loneliness with kindness. 

 observed 2 groups for 6 weeks; 1 that performed acts of kindness for themselves and 1 that conducted good deeds for others.

 The group that behaved altruistically flourished psychologically through improved social relationships and feelings of greater joy and wellbeing.

 suggested that how we treat loneliness is a bellwether of not only society’s emotional and physical health but also its moral health.

 In a society where many prioritize themselves, we need to help our patients—and ourselves—commit to being both present and compassionate for each other.

Ironically, suicide rates generally dip after major events that are shared by large populations.

 During COVID-19, CDC statistics found provisional 

 Provisional suicide mortality rate estimates provide an early indication of shifts in suicide mortality trends.

 After the 9/11 terrorist attacks, suicide rates in New York declined significantly during the 180 days after the event.

 Researchers suggest that a “pulling together” effect may be the reason behind this phenomenon. Shared experiences during COVID-19 led to a powerful sense of togetherness that helped to keep suicidal thoughts in check. 

 suggested that the “need to belong is so powerful that, when satisfied, it can prevent suicide.”

 It noticed that fewer suicides occurred on Super Bowl Sundays, likely due to an increase of shared membership and group interaction on those days.

It is this line of reasoning that developed the 

 First, suicide ideation occurs as a reaction to feelings of psychological pain and hopelessness. Second, feelings of connectedness were a key protective factor against escalating ideation. Third, suicide follows ideation when a someone determines they have the disposition and practical capacities to carry out the event.

To be sure, the stress of COVID-19 has affected mental health around the world. 

 reported that more than 40% of respondents had symptoms of anxiety or depression.

 It is interesting that while suicide rates declined, depression rates have increased. Major events that affect a whole population have an interesting effect in decreasing suicide while increasing rates of depression. Additionally, 26% indicated that they had started or increased substance use as a way to cope.

As psychiatrists, we tend to be biased in thinking that everything can be fixed with medication; however, the danger is that we forget to see the human person in front of us. While medication can help, often their problem is much more complex and needs more than medication treatment. We should not overlook patients we think are lonely and instead provide tips, such as being active on social media and staying in touch with friends through Zoom and Facebook. Although in-person relationships are always better than virtual ones, virtual ones are better than nothing. The worst thing to do when lonely is to completely isolate and not talk to anyone through social media. 

As psychiatrists, we are on the front lines and can affect whether some people live or die. Let us rise to the occasion and treat everyone with kindness and compassion and in doing so, save thousands of lives.

is staff psychiatrist at Community Psychiatry in San Jose, CA.

1. Harvard University. Loneliness in America: How the pandemic has deepened an epidemic of loneliness and what we can do about it. February 2021. Accessed May 13, 2021. 

https://mcc.gse.harvard.edu/reports/loneliness-in-america

2. Harvard Health Publishing. Loneliness has same risk as smoking for heart disease. June 16, 2016. 

https://www.health.harvard.edu/staying-healthy/loneliness-has-same-risk-as-smoking-for-heart-disease

3. Weeks DG, Michela JL, Peplau LA, Bragg ME. (1980). Relation between loneliness and depression: A structural equation analysis. 

Journal of Personality and Social Psychology. 1980;39

4. Kahneman D, Krueger AB, Schkade DA, et al. A survey method for characterizing daily life experience: the day reconstruction method. 

5. Lonely. Merriam-Webster. Accessed May 13, 2021. 

https://www.merriam-webster.com/dictionary/lonely

6. Hawkley LC, Cacioppo JT. Loneliness matters: a theoretical and empirical review of consequences and mechanisms. 

7. Besser A, Flett GL, Davis RA. Self-criticism, dependency, silencing the self, and loneliness: A test of a mediational model. 

8. Breann A. What is the loneliness loop and how can I break free from it? Younique Foundation. Accessed May 13, 2021. 

https://youniquefoundation.org/what-is-the-loneliness-loop-and-how-can-i-break-free-from-it

9. Remes O. Loneliness is contagious – and here’s how to beat it. Cambridge University. July 16, 2018. 

https://www.cam.ac.uk/research/discussion/loneliness-is-contagious-and-heres-how-to-beat-it

10. Cacioppo JT, Fowler JH, Christakis NA. Alone in the crowd: the structure and spread of loneliness in a large social network. 

11. Nietzsche F. A Nietzche Reader Selected and translated. Penguin Books; 1984.

12. Harlow HF, Dodsworth RO, Harlow MK. Total social isolation in monkeys. Proc Natl Acad Sci USA.1965;54(1):90-97.

13. BBC, University of Manchester. The BBC Loneliness Experiment. Accessed April 30, 2021. 

https://www.seed.manchester.ac.uk/education/research/impact/bbc-loneliness-experiment/

14. Courtet P, Olié E, Debien C, et al. Keep socially (but not physically) connected and carry on: preventing suicide in the age of COVID-19. 

15. Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States, 1999–2018. NCHS Data Brief, no 362. National Center for Health Statistics; 2020.

16. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. 

17. Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT. A short scale for measuring loneliness in large surveys: Results from two population-based studies. 

18. Flückiger C, Del Re AC, Wampold BE, Horvath AO. The alliance in adult psychotherapy: A meta-analytic synthesis. 

19. Russell D, Peplau LA, Cutrona CE. The revised UCLA Loneliness Scale: concurrent and discriminant validity evidence. 

20. Fossi Djembi L, Vaiva G, Debien C, et al

 Changes in the number of suicide re-attempts in a French region since the inception of VigilanS, a regionwide program combining brief contact interventions (BCI). 

21. Pittman M, Reich B. Social media and loneliness: Why an Instagram picture may be worth more than a thousand Twitter words. 

22. Cauberghe V, Van Wesenbeeck I, De Jans S, et al. How adolescents use social media to cope with feelings of loneliness and anxiety during COVID-19 lockdown. 

Cyberpsychology, Behavior, and Social Networking

23. Nelson SK, Layous K, Cole SW, Lyubomirsky S. Do unto others or treat yourself? The effects of prosocial and self-focused behavior on psychological flourishing. 

24. Weissbourd R, Batanova M, Lovison V, Torres E. Loneliness in America: How the pandemic has deepened an epidemic of loneliness and what we can do about it. Harvard Graduate School of Education. February 2021. 

25. Nishio A, Akazawa K, Shibuya S, et al. Influence on the suicide rate two years after a devastating disaster: A report from the 1995 Great Hanshin-Awaji earthquake. 

26. Ahmad FB, Anderson RN. The leading causes of death in the US for 2020. 

https://jamanetwork.com/journals/jama/fullarticle/2778234

27 Ahmad FB, Cisewski JA, Miniño A, Anderson RN. Provisional Mortality Data - United States, 2020. 

28. Claassen CA, Carmody T, Stewart SM, et al. Effect of 11 September 2001 terrorist attacks in the USA on suicide in areas surrounding the crash sites. 

29. Joiner TE, Hollar D, Van Orden K. On Buckeyes, Gators, Super Bowl Sunday, and the miracle on ice: “Pulling together” is associated with lower suicide rates. 

30. Klonsky ED, May AM. The Three-Step Theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. 

31. Czeisler ME, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. Centers for Disease Control and Prevention. 2020;69(32):1049-1057.

The pandemic has kept people apart. What are the mental health consequences of being alone? And what would be the benefits of getting back together? 

COVID-19 Loneliness

Patients with cancer are at increased risk for both suicidal ideation and completed suicide due to a combination of biological and psychological factors that must be addressed to increase quality of life. More research is needed to determine the best methods of screening, evaluation, and treatment for suicidal thoughts and actions in this population.

- Cancers with the highest suicide risk include head and neck, lung, and pancreas.

- Health care providers do not feel adequately prepared to assess patients for suicidality.

- Increased risk is associated with older age, male gender, increased paid, lack of social supports, preexisting mood disorders, hopelessness; iatrogenic and biological factors must be assessed and addressed.

Cancer has plagued humanity since the beginning of recorded history. The first mention of cancer in the literature appeared in the Edwin Smith papyrus, dated ~3000BC. Surviving documents from ancient Greek and Roman physicians detail attempts at diagnosing and curing and give us the language we use today (oncos and cancer, respectively).

Although the overall prevalence of mortality due to cancer has been decreasing, it is still the second leading cause of death in the United States, responsible for 599,108 (21.3% of total) deaths in 2017.

 In comparison, suicide ranks 10th in this list, with 47,173 (1.7% of total) deaths. The most common cancers worldwide are lung, breast, 

, prostate, skin, and stomach; lung, colorectal, stomach, liver, and breast cancers account for the most deaths.

Changing attitudes toward suicide has altered the recorded prevalence over time, but it has always been a factor in human death. The desire to control, to some extent, the timing and manner of one’s death has always been a human temptation, and this draw increases when physical or emotional distress are present. Although estimates vary, patients with cancer are, at minimum, twice as likely to die by suicide. Moreover, having psychiatric care pre-diagnosis may not mitigate this increased risk.

Suicide risk is not the same for all types of cancer, nor is it consistent over the disease course (

).Several studies have found that suicide risk is at least twice that of the general population and is highest immediately after diagnosis.

Among cancers with the highest suicide risk are those affecting the head and neck, lung, pancreas, and larynx/pharynx. Prostate cancer has a higher suicide rate in the first year after diagnosis, but lower overall unless metastatic disease is found, with additional increased risk when treatment is defined but not received. Unique to cancer is that the risk of suicide persists more than 15 years past diagnosis.

In addition to increased suicide risk, patients with head and neck cancers have higher depression scores than the general population even before a cancer diagnosis, leading to the question whether this subset of patients are struggling with a biological cause in addition to diagnosis-related symptoms.

 Complicating these cases is the well-known association of many head and neck cancers with tobacco, alcohol, and other substance use, leading to the question of whether the pre-existing mood disorders lead to substance use that increases the risk of cancer. The relative increase in number of cases linked to human papillomavirus instead of substance use may alter this picture.

Regarding lung cancer, although the risk of suicide has been decreasing, Rahouma and colleagues6 found that these patients are at a higher risk than those with the more prevalent breast, prostate, or colorectal cancer. Furthermore, a large proportion of suicides may occur in patients with possibly non-fatal disease.

The risk in patients with breast cancer has been relatively stable over the last 4 decades and may be linked to whether the patient has undergone surgery. Findings from Simpson and colleagues

 indicate that penile cancer patients have one of the lowest suicide rates and, in their study, all patients who died by suicide had undergone surgical intervention. The link between surgical intervention and suicide risk may be linked to cosmetic effects, particularly as they affect sexual organs and can potentially alter patients’ view of their desirability and sexual roles.

In colorectal cancer, risk differs depending on the site of the lesion. Distally located disease is linked to a higher rate of suicide. This effect may be due to the more severe effects of distal disease on quality of life. Suicide risk in patients with stomach cancer was 

 with diarrhea, which can have a significant impact on lifestyle.

 It is not surprising that patients with terminal cancers report significantly more suicidal ideation.

One of the challenges in suicide prevention is determining the most effective ways to assess risk and screen for suicidal thoughts and intentions. Very little information has been collected regarding formal suicide risk assessment in cancer patients 

 found that health care providers did not feel adequately prepared to ask about suicidality or provide support and resources to patients.

The Columbia Suicide Severity Rating Scale (C-SSRS) is widely used for assessing suicidal intent, acts of furtherance, and suicide attempts. It has been studied and validated, and it is available in a variety of languages. It is free and designed to be used by anyone, including people without prior mental health care experience; there are versions specifically for people with cognitive impairments and children. However, it does not provide guidance as to full assessments or further steps once the screening is positive.

The Beck Hopelessness Scale asks true/false questions about future orientation, motivation, and expectations in order to assess negative feelings about the future. It can be used as an indirect evaluation of suicidal thoughts but does not address it directly. The detailed interpretation report can be very useful in assessing changes over time, but although the questions can be asked by anyone, the interpretation requires a trained professional.

The Hamilton Depression Scale (HAM-D) is a relatively brief questionnaire that asks about a variety of symptoms of depression; suicide is mentioned in 1 of the 17 questions, which are on a graded scale. It does not ask about atypical symptoms and, while it has relatively high sensitivity, specificity is low.

The Patient Health Questionnaire-9 (PHQ-9) is a brief set of questions designed to be asked and reviewed by any health care professional, with recommendations of when to advise further assessment by a mental health professional. It has shown to be reliable and valid in multiple studies. Like the HAM-D, it has relatively high sensitivity and low specificity.

Multiple studies have shown cancer as an independent risk factor for completed and attempted suicide. Spoletini and colleagues

 contrasted suicide in the general population, which they attributed to “genetic and psychological vulnerability to stress,” to suicide in cancer patients, which involved the “intrinsic bio-psychological vulnerability to distress” linked to changes in the immune system associated with cancer. Thus far, research has not identified consistent risk factors that enable the jump from suicidal ideation to suicide attempts. Underlying factors such as mood disorders may increase risk but require “additional precipitating events or conditions.”

Hopelessness and rumination are primary cognitive predictors; and hopelessness may be associated with recurrent self-harm. Depression is a major risk factor, as it is in the general population, but the cancer population is at higher baseline risk for depression, which has been linked to immunological changes.

 Identification and treatment of depression in cancer patients has been shown to decrease morbidity and mortality.

An important component of identifying at-risk patients is to determine the characteristics of those who historically have higher rates of suicide. As in the general population, the overall suicide rate in patients with cancer is linked to male gender, white race, lack of a partner and/or other social supports, and preexisting emotional or anxiety disorders as significant risk factors.

 In addition, older age, pain, advanced, disease, and poor prognosis are variables specific to this population that increase the risk of both suicidal ideations and suicide. Physical illnesses in general, particularly those associated with physical pain with consequent lifestyle limitations, are consistent risk factors that play a role in at least 25% of suicides, and the correlation increases with age.

 Patients with significant uncontrolled pain are at higher risk—thus a key component of cancer treatment must be adequate pain control. Minimal information has been collected on how substance use as reaction to a cancer diagnosis contributes to the risk of suicide. This may prove to be an important factor (

Although few thorough examinations of the methods typically used for suicide have been conducted, the National Cancer Institute 

 that overdose with painkillers and sedatives is the most common method of suicide used by cancer patients, and most of these occur at home.

 Despite this, screening for other methods of suicide (particularly firearms) should not be neglected.

A general understanding of suicidal ideation and behaviors involves alterations in the serotonin and HPA systems. The effects of a disease like cancer that alters immune system function can also alter these axes, which may result in increased risk of suicide. Independently of co-occurring cancer, the immune system is altered in depression (changes in cytokine and cell mediated immunity, changes in HPA axis) and may contribute to the development of depression in a reciprocal manner.

Depression secondary to medical causes should be ruled out in cancer patients. This typically includes an evaluation of B12 and folate levels, anemia, thyroid hormone imbalance, and adrenal hormone imbalance. The utility of assessing electrolyte abnormalities, including sodium, potassium, and magnesium remains unclear, although there is considerable interest in the effect of imbalances on mental health.

To further complicate this picture, several medications used to treat cancer have been linked to depression, such as corticosteroids, L-asparaginase, interferon-alpha, and amphotericin B.

Careful review of medication regimens and treatment alternatives may offer options for minimizing the effect of cancer therapy on mental health.

The “escape model” of suicidal drive may come into play, particularly in patients with a terminal diagnosis. This model postulates that the desire to escape from intolerable distress, combined with increased awareness of the factors contributing to that distress, leads to suicide.

 Accordingly, cancers with less than 5-year survival rates correlated to higher suicide risk, leading some to wonder whether the type of cancer is more important than the cancer diagnosis.

There are confusing data regarding the complicated mix of desire to speed up death, depression, hopelessness, and suicide risk. It appears that patients with baseline depression are more likely to want hastened death, expressing this desire up to 4 times as often, but Porta-Sales and colleagues

 found that simply discussing the wish for more rapid death did not cause distress, and that nearly 80% of patients felt it was an important topic for the care team to discuss.

Studies of suicidal ideation and completed suicide in adult cancer patients and survivors make up the bulk of the research in this area. As treatments and survival rates for childhood cancers improve, long-term studies of this population must include this information to more fully understand the lifelong effects of cancer treatment in children and adolescents, particularly since suicide is the top cause of death in the young adult populations of many developed countries. Gunnes and colleagues

 showed an increased risk of suicide in Norwegian patients aged 23 to 48 years who had a diagnosis of cancer before the age of 25. At exceptional risk were survivors of brain and testicular tumors, as well as leukemia. An American study did not replicate this finding but reported an increased risk of suicidal ideation compared with sibling controls.

 The average age of those who reported a first incident of suicidal ideation was 34 years, and they were, on average, 26 years past diagnosis. This is a serious example of how the sequelae of childhood cancer treatment can persist far into adulthood.

Is Refusal of Treatment a Form of Suicide?

Complicating the discussion of suicide in cancer patients is the subject of refusal of treatment. Is this considered suicide? Frenkel

 noted that “the unique patients who refuse conventional treatment are at times self-directed, confident, and active, and have thought deeply about the meaning of life and cancer and about their cancer treatment options.” What does it mean to have the ability to choose, to some extent, when we will die? This controversy has been taken all the way to the Supreme Court, with Justice Brandeis writing in Olmstead vs US that “the right to be left alone . . . the most comprehensive of rights and the right most valued by civilized men,” and Justice Burger clarifying that “nothing in this utterance suggests that Justice Brandeis thought an individual possessed their rights only as to sensible beliefs, valid thoughts, reasonable emotions.”

 Physicians are trained that the ultimate goal is to save or at least prolong life, but often neglected is the consideration of quality of life and patients’ desire to live, and die, in a manner they can, to some extent, control. Isenberg-Grzeda and colleagues

 reported on 3 patients who attempted suicide after being deemed ineligible for medical assistance in dying, further exemplifying the desire to have some say over the end of their lives.

Treatments can be quite similar to the treatment of depression in the general population, with psychotherapy and pharmacotherapy (selective serotonin reuptake inhibitors, selective serotonin-norepinephrine reuptake inhibitors, mirtazapine, trazodone) forming the basis. The most recent review of antidepressant therapy for depression in cancer patients did not show a significant improvement from placebo, but 

 noted that there were few studies from which to draw this information and noted that much more research is needed in this area.

Psychotherapy, no matter how brief, can help patients adjust to their new health circumstances and reassess their view of their life up until their diagnosis and goals going forward. In addition, special considerations such as the influence of altered immune activity and the effects of chemotherapy must also weigh into treatment decisions. Moreover, prescribers must be judicious in choosing medications that can be expected to show some positive effect within the patient’s expected lifetime, which may be significantly shortened. Stimulants may be useful in treating symptoms of fatigue and inattention that are common during cancer treatment. Close collaboration with the oncologic team can help to optimize mental health during cancer treatment.

Suicide and cancer are the top 10 causes of death in the adult population of the United States, and the world. Patients with cancer are at increased risk for both 

 and completed suicide. Factors contributing to this increase are both biological and psychological and components must be addressed in a timely fashion to increase quality of life. A refusal of treatment must not automatically be considered an instrument of suicide but viewed as a complex decision factoring in goals of care, particularly quality of life. More research is needed to determine how best to evaluate and treat oncology patients for suicidal thoughts and behaviors.

is faculty member, Department of Psychiatry, Albert Einstein Medical Center, Philadelphia, PA. The authors have nothing to disclose regarding this article.

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Antidepressants for the treatment of depression in people with cancer

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Clinical and epidemiological factors associated with suicide in colorectal cancer

Patients with cancer are at increased risk for both suicidal ideation and completed suicide. The authors discuss factors contributing to this increase in both biological and psychological realms.

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